successful management of an omphalomesenteric

Pediatric Surgery
SUCCESSFUL MANAGEMENT OF AN
OMPHALOMESENTERIC FISTULE IN
NEWBORN PERIOD
YAVUZ YILMAZ*
GAMZE DEMİREL**
HÜLYA Ö. ULU*
SUMMARY: Umbilical cord problems are the major causes of referrals to pediatric surgery clinics during
newborn period and most patients present with a mass or drainage from the umbilicus. Here we present a male
newborn with yellowish umbilical cord drainage on fourth day of life. Omphalomesenteric fistule was determined and the patient was operated successfully.
Key words: omphalomesenteric fistule, umbilical drainage, newborn
INTRODUCTION
The umbilicus functions as a channel that allows
blood flow between the placenta and fetus and it has an
important role in the development of the intestine and the
urinary system (1). Umbilical cord problems are the major
causes of referrals to pediatric surgery clinics during
newborn period and most patients present with a mass or
drainage from the umbilicus (29). Here, we report a newborn with omphalomesenteric fistule presenting with
umbilical cord drainage on the first days of life.
CASE REPORT
A-four-day old male was referred to the pediatric
surgery clinic for the evaluation of umbilical cord
drainage. The patient’s perinatal course was uncomplicated and he was delivered vaginally at 40 weeks gestation as 3300 g of weight. One day following delivery he
was discharged to home. On physical examination on
*From Neonatology Unit, Pediatric Surgeon, Ministry of Health Zekai
Tahir Burak Maternity and Teaching Hospital, Ankara, Turkey.
**From Neonatology, Neonatology Unit, Ministry of Health Zekai Tahir
Burak Maternity and Teaching Hospital Ankara, Turkey.
4th day of life, there was an atypical, hyperemic mass
with yellowish, bad odor on umblicus (Figure 1). After
catheterization of the umbilical cord with a 8 french feeding catheter, an X-ray was performed with contrast material and omphalomesenteric fistule joining to ileum was
diagnosed (Figure 2). Abdominal ultrasonography for
evaluation of the possibility of additional anomalies was
normal.
The patient underwent umbilical stump exploration
under general anesthesia after performing routine hematologic and biochemical laboratory evaluations. The skin
was incised circumferentially around the umblicus and
the layers along the fistule tract were incised. The fistule
and the ileal segment that it connected were thrown out
through the incision. The fistule that was around 10 cm
length was dissected from the ileum, and afterwards the
ileum was anastomosed (Figure 3). The operation was
finished after umblicoplasty.
The patient’s post-operative course was unremarkable, and he was discharged to home on the seventh
post-operative day.
Medical Journal of Islamic World Academy of Sciences 19:4, 181-183, 2011
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MANAGEMENT OF OMPHALOMESENTERIC FISTULE
DISCUSSION
Omphalomesenteric duct is the embryonic structure
connecting the primary yolk sac to the embryonic midgut
and its malformations may range from a completely
patent omphalomesenteric duct to fibrous cords connecting the umbilicus to the distal ileum, cysts, umbilical
hernias, and Meckel diverticulum (3-5). The omphalomesenteric duct normally closes between the 5th and the
7th week of gestation. At 10th week of gestation, whole
intestine locates into the abdominal cavity and
omphalomesenteric duct turns to a fibrous band (6). The
persistance of an open duct is rare. If the duct partially
obliterates leaving a blind pouch on the antimesenteric
surface of the ileum, then Meckel’s diverticulum develops, which is the most common anomaly in this spectrum with an incidence of 2% (7, 8). If the distal segment
of the duct remains open, an omphalomesenteric sinus
develops and if both ends of the duct remain open fistule
with a discharge of fecal material develops (4).
About 60 deliveries take place in a day in our tertiary maternity hospital and those infants are followed by
a neonatologist at early period of their life. Umbilical cord
problems are refered to our pediatric surgery clinic. In a
five-year period this is the unique patient that was diagnosed having an omphalomesenteric fistule.
Umbilical discharge should raise the suspicion of a
patent omphalomesenteric duct (2). Umbilical granuloma
is one of the patologies with differential diagnosis of
omphalomesenteric fistule (9). Umbilical granuloma
responds to silver-nitrate stick. The presence of a lumen
in the umbilical cord and yellowish drainage with bad
odor similar to fecal mass should be considered as a
patent omphalomesenteric duct (10). The exact diagnosis can be done by a fistulogram after catheterization of
the duct by an opaque solution (4).
Urachal fistules are opened to the umblicus and
they should be remembered in differential diagnosis of
omphalomesenteric fistule. The drainage of urachal fistule is like urine. The fistulogram shows that the fistule
opens to the bladder (11).
Surgical excision, either by open or laparoscopic is
the treatment of choice for omphalomesenteric fistule.
Surgical procedure comprises of dissecting the skin
around the umblicus, reaching the intestinal segment
that the fistule joints, resecting the fistule and anasto182
YILMAZ, DEMİREL, ULU
Figure 1: Red mass around the umblicus
Figure 2: Fistulogram showing the omphalomesenteric duct
Figure 3: Fistule between the umblicus and ileum.
Medical Journal of Islamic World Academy of Sciences 19:4, 181-183, 2011
MANAGEMENT OF OMPHALOMESENTERIC FISTULE
mosing the intestinal segment. The surgery is finished
by umblicoplasty (12).
In conclusion, we detected an omphalomesenteric
fistule in a patient with yellowish drainage at umblicus
REFERENCES
1. Snyder CL: Current management of umbilical abnormalities
and related anomalies. Semin Pediatr Surg, 16(1): 41-49, 2007.
2. Vane DW, West KW, Grosfeld JL: Vitelline duct anomalies.
Experience with 217 childhood cases. Arch Surg, 122(5): 542-547,
1987.
3. Sherer DM: Prenatal ultrasonographic assessment of the
middle cerebral artery: a review. Obstet Gynecol Surv, 52(7): 444455, 1997.
4. Taranath A, Lam A: Ultrasonographic demonstration of a
type 1 omphalomesenteric duct remnant. Acta Radiol, 47(1): 100102, 2006.
5. Durakbasa CU et al: Symptomatic omphalomesenteric duct
remnants in children. Pediatr Int, 52(3): 480-484, 2010.
6. Moore TC: Omphalomesenteric duct malformations. Semin
Pediatr Surg, 5(2): 116-123, 1996.
7. Cullen JJ et al: Surgical management of Meckel's diverticulum. An epidemiologic, population-based study. Ann Surg, 220(4):
564-568, 1994.
8. Kamii Y et al: Spontaneous regression of patient
omphalomesenteric duct: from a fistula to Meckel's diverticulum. J
Pediatr Surg, 27(1): 115-116, 1992.
YILMAZ, DEMİREL, ULU
and treated successfully with surgical approach. Physicians and care givers should be aware of patent
omphalomesenteric duct in patients with umbilical cord
anomalies.
9. Sanchez-Castellanos ME et al: Persistence of the
omphalomesenteric duct. Childhood differential diagnosis of umbilical granuloma. Actas Dermosifiliogr, 97(6): 404-405, 2006.
10. Konvolinka CW: Patent omphalomesenteric duct. Surgery,
131(6): 689-690, 2002.
11. Fink D et al: Persistent ductus omphaloentericus--a possible cause of bleeding umbilicus. Gynakol Geburtshilfliche Rundsch,
35(1): 26-28, 1995.
12. Hasegawa T et al: Transumbilical resection and umbilical
plasty for patent omphalomesenteric duct. Pediatr Surg Int, 13(2-3):
180-181, 1998.
Medical Journal of Islamic World Academy of Sciences 19:4, 181-183, 2011
Correspondence:
Yavuz Yılmaz
Neonatology Unit, Pediatric Surgeon,
Ministry of Health
Zekai Tahir Burak Maternity and
Teaching Hospital, Ankara, TURKEY.
e-mail: [email protected]
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